title: Clinical outcomes of patients with low-flow, low-gradient, severe aortic stenosis and either preserved or reduced ejection fraction undergoing transcatheter aortic valve implantation.
abstract: OBJECTIVE
  Our aim was to evaluate the invasive haemodynamic indices of high-risk symptomatic patients presenting with 'paradoxical' low-flow, low-gradient, severe aortic stenosis (AS) (PLF-LG) and low-flow, low-gradient severe AS (LEF-LG) and to compare clinical outcomes following transcatheter aortic valve implantation (TAVI) among these challenging AS subgroups.
  
  
  RESULTS
  Of 534 symptomatic patients undergoing TAVI, 385 had a full pre-procedural right and left heart catheterization. A total of 208 patients had high-gradient severe AS [HGAS; mean gradient (MG) ≥40 mmHg], 85 had PLF-LG [MG ≤ 40 mmHg, indexed aortic valve area [iAVA] ≤0.6 cm(2) m(-2), stroke volume index ≤35 mL/m(2), ejection fraction (EF) ≥50%], and 61 had LEF-LG (MG ≤ 40 mmHg, iAVA ≤0.6 cm(2) m(-2), EF ≤40%). Compared with HGAS, PLF-LG and LEF-LG had higher systemic vascular resistances (HGAS: 1912 ± 654 vs.
  2006 ± 586 vs.
  2216 ± 765 dyne s m(-5), P = 0.007) but lower valvulo-arterial impedances (HGAS: 7.8 ± 2.7 vs.
  6.9 ± 1.9 vs.
  7.7 ± 2.5 mmHg mL(-1) m(-2), P = 0.027). At 30 days, no differences in cardiac death (6.5 vs. 4.9 vs. 6.6%, P = 0.90) or death (8.4 vs. 6.1 vs. 6.6%, P = 0.88) were observed among HGAS, PLF-LG, and LEF-LG groups, respectively. At 1 year, New York Heart Association functional improvement occurred in most surviving patients (HGAS: 69.2% vs.
  71.7% vs.
  89.3%, P = 0.09) and no significant differences in overall mortality were observed (17.6 vs. 20.5 vs. 24.5%, P = 0.67). Compared with HGAS, LEF-LG had a higher 1 year cardiac mortality (adjusted hazard ratio 2.45, 95% confidence interval 1.04-5.75, P = 0.04).
  
  
  CONCLUSIONS
  TAVI in PLF-LG or LEF-LG patients is associated with overall mortality rates comparable with HGAS patients and all groups profit symptomatically to a similar extent.
authors.affiliation: Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, 3010 Bern, Switzerland.
authors.forename: Crochan J
authors.initials: CJ
authors.lastname: O'Sullivan
authors.forename: Stefan
authors.initials: S
authors.lastname: Stortecky
authors.forename: Dik
authors.initials: D
authors.lastname: Heg
authors.forename: Thomas
authors.initials: T
authors.lastname: Pilgrim
authors.forename: Nicola
authors.initials: N
authors.lastname: Hosek
authors.forename: Lutz
authors.initials: L
authors.lastname: Buellesfeld
authors.forename: Ahmed A
authors.initials: AA
authors.lastname: Khattab
authors.forename: Fabian
authors.initials: F
authors.lastname: Nietlispach
authors.forename: Aris
authors.initials: A
authors.lastname: Moschovitis
authors.forename: Thomas
authors.initials: T
authors.lastname: Zanchin
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meier
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.forename: Peter
authors.initials: P
authors.lastname: Wenaweser
mesh_terms: D000369:Aged, 80 and over; D000704:Analysis of Variance; D001021:Aortic Valve; D001024:Aortic Valve Stenosis / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods*; D004452:Echocardiography; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000503:physiopathology; D008297:Male; D011475:Prosthesis Failure; D012189:Retrospective Studies; D013318:Stroke Volume / Q000502:physiology; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left
keywords: Aortic stenosis; Hemodynamics; Transcatheter aortic valve implantation